Cardiovascular emergencies
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Cardiovascular Emergencies. …time is myocardium!. Statistics. Cardiovascular disease (CVD) claimed over 1 million lives in 2004. CVD has been the leading cause of death for Americans since 1900. Sudden cardiac death accounts for over 40% of these deaths.

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Cardiovascular emergencies

Cardiovascular Emergencies

…time is myocardium!


  • Cardiovascular disease (CVD) claimed over 1 million lives in 2004.

  • CVD has been the leading cause of death for Americans since 1900.

  • Sudden cardiac death accounts for over 40% of these deaths.

  • The majority of our 911 responses are for chest pain.

Controllable risk factors
Controllable Risk Factors


High blood pressure

Elevated cholesterol levels

Elevated blood glucose levels


Lack of exercise


Uncontrollable risk factors
Uncontrollable Risk Factors


Family history




  • Red blood cells:

    • Carries oxygen to tissues and cells

    • Removes CO2 and waste

  • White blood cells:

    • Fight infection

  • Platelets:

    • Helps blood clot

Cardiac compromise
Cardiac Compromise

  • Chest pain results from ischemia.

  • Ischemic heart disease involves decreased blood flow to the heart.

  • If blood flow is not restored, the tissue dies (infarct).

  • Injury leads to inadequate heart function and death.

Cardiovascular emergencies

…you are dispatched to a 67 year- old male c/o 9/10 “crushing” chest pressure that radiates to his jaw. He is also complaining of shortness of breath and nausea, with no previous cardiac history…

W hat are you thinking

…what are YOU thinking?

Chest pain pathophysiology
Chest Pain Pathophysiology

  • Mediastinum:

    • Angina: stable or unstable

    • AMI

    • Esophagitis, esophageal rupture

    • Pericarditis

    • Mediastinal air

    • Thoracic dissection

    • Mitral valve prolapse

Chest pain pathophysiology1
Chest Pain Pathophysiology

  • Chest Wall:

    • Traumatic contusion/tamponade

    • Cysts and infections

    • Rib cartilage inflammation

    • Shingles (Herpes Zoster)

    • Muscle strain, overuse syndromes

Chest pain pathophysiology2
Chest Pain Pathophysiology

  • Lungs and pleura:

    • Pleurisy

    • Pneumonia

    • Pneumothorax, hemothorax

    • Pulmonary embolus

    • Asthma, bronchitis, URI

Chest pain pathophysiology3
Chest Pain Pathophysiology

  • Abdomen:

    • Gallbladder (cholecystitis, stones)

    • Stomach (gastritis, GERD, perforated peptic ulcer)

    • Pancreas (pancreatitis)

    • Esophagitis, perforation

Chest pain
Chest Pain

  • Psychogenic:

    • Stress

    • Hyperventilation

    • Anxiety and panic attacks

Classic symptoms
Classic Symptoms

  • Pressure, fullness, heaviness, squeezing pain in center of chest with radiation

  • Diaphoresis

  • Nausea

  • Shortness of breath

  • Weakness

Frequency of symptoms
Frequency of Symptoms

  • Diaphoresis 78%

  • Chest pain 64%

  • Nausea 52%

  • Shortness of breath 47%

  • No signs/symptoms 25%

    N Engl J Med 1984;311:1144-7

Atypical presentations
Atypical Presentations

  • Common in the elderly, diabetics, and females:

    • Unusual fatigue

    • Sudden onset of unusual shortness of breath

    • Nausea, dizziness

    • Belching, burping, indigestion

    • Palpitations, new dysrhythmia

    • Pain only in jaw, neck, back, arm

Angina pectoris
Angina Pectoris otherwise!

  • Chest pain caused when heart tissues do not get enough oxygen for a brief period of time.

  • Typically crushing or squeezing.

  • Onset with the 3-E’s.

  • Usually resolves with rest or meds.

  • May be difficult to diagnose from AMI

Angina otherwise!

Acute coronary syndrome
Acute Coronary Syndrome otherwise!

Used to describe the range of conditions from unstable angina to AMI.

Signs and symptoms usually caused by acute myocardial ischemia.

Acs signs symptoms
ACS Signs & Symptoms otherwise!

  • Shortness of breath

  • Signs of inadequate perfusion

  • Chest pain, pressure, or discomfort (with or without radiation to back, neck, jaw, arm, wrists)

  • Nausea

  • Weakness/syncope

  • Dysrhythmias

Acute myocardial infarct
Acute Myocardial Infarct otherwise!

Usually caused by the same mechanism as angina only with resulting tissue death.

Time is myocardium:

Consequences can be serious:

Congestive heart failure

Cardiogenic shock

Sudden death

Cardiovascular emergencies
AMI otherwise!

Cardiogenic shock
Cardiogenic Shock otherwise!

Heart lacks power to force blood through the circulatory system.

Brought on when 40% of left ventricle is infarcted.

Onset may be immediate or not apparent for 24 hours.

Signs symptoms
Signs & Symptoms otherwise!

  • Altered LOC

  • Rapid, shallow breathing

  • Restlessness and anxiousness

  • Pale, cool skin

  • Tachycardia/dysrhythmia

  • Hypotension

Congestive heart failure
Congestive Heart Failure otherwise!

Occurs when the ventricles are damaged.

Heart tries to compensate with increased heart rate.

Enlarged, ineffective left ventricle

Fluid builds up into lungs or body as “pump” fails.

Cardiovascular emergencies
CHF otherwise!

Signs symptoms1
Signs & Symptoms otherwise!

  • Fatigue

  • Cough with pink, frothy sputum

  • Dypsnea, tachypnea

  • Pulmonary edema

  • Agitation and confusion

  • Hypertension

  • Pedal edema, ascities

Signs symptoms2
Signs & Symptoms otherwise!

Aortic aneurysm
Aortic Aneurysm otherwise!

Signs symptoms3
Signs & Symptoms otherwise!

  • Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.”

  • Anxiety

  • Diaphoresis

  • Nausea

Cardiac tamponade
Cardiac Tamponade otherwise!

  • Trauma induced, filling of the pericardial sac with blood.

  • Signs of shock

  • JVD

  • Decrease pulse pressures

Esophageal rupture
Esophageal Rupture otherwise!

  • Usually underlying alcohol abuse.

  • Shock signs.

  • Coughing up bright red blood.

Pericarditis otherwise!

  • Inflammation of the pericardium caused by infection.

  • Usually presents as sharp discomfort.

  • Changes with breathing and movement.

Chest pain assessment
Chest Pain Assessment otherwise!

BSI/Scene Safety

Initial Assessment (Sick/Not Sick)

Focused Exam

Detailed Exam


Treatment and Plan

Initial assessment
Initial Assessment otherwise!

  • 60second clinical picture to determine if Sick or Not Sick (Oxygen)

  • Based upon your initial impression:

    • Body position

    • skin signs and color

    • respiratory rate and effort

    • mental status

    • pulse rate and character

  • Correct immediate life threats!

Focused exam s
Focused Exam (S) otherwise!

Your subjective findings are based upon what the patient or historian tells you:

Patient Age


Chief Complaint

Focused exam s1
Focused Exam (S) otherwise!

SAMPLE History

  • Signs/Symptoms (associated with cardiac chest pain):

    • Diaphoresis (78%)

    • Shortness of Breath (47%)

    • Pain/discomfort (64%)

    • Nausea/vomiting (52%)

    • No signs or symptoms (25%)

      N Eng Journal Med 1984;311:11444-7

Focused exam s2
Focused Exam (S) otherwise!

  • Onset –

    “When and at what time did it start”

  • Provocation –

    “Does anything make it better or worse?”

    “Does it change with position, palpitation, inspiration?”

  • Quality –

    “Describe the pain/discomfort in your own words”

Focused exam s3
Focused Exam (S) otherwise!

  • Region/Radiation –

    “Where does it start?”

    “Does it radiate anywhere?”

  • Severity –

    “On a scale of 1 to 10, what was the pain/discomfort at onset?”

    “What is the pain/discomfort at now?’

  • Time –

    “When did this episode start?”

    “How long has it been going on?”

Focused exam s4
Focused Exam (S) otherwise!

  • Allergies

  • Medications –

    Cardiac meds = cardiac problems.

    Ask about OTC meds, natural supplements, vitamins?

  • Past Medical History –

    “Do you have any cardiac history?”

    “Risk factors such as smoking, diabetes, HTN, weight/diet?””

Focused exam s5
Focused Exam (S) otherwise!

  • Last Oral Intake

  • Events Leading to Call –

    “What were you doing when this event started?”

    Think activity induce vs. non activity

Listen to the patient

Listen to the patient… otherwise!

…they will tell you exactly what is wrong!

Focused exam o
Focused Exam (O) otherwise!

Objective findings from your physical exam of the patient.

  • Look for evidence of trauma/injury

  • Evaluate:

    • Level of consciousness

    • Skin color and temperature

    • Respiratory rate and effort

    • Pupillary reaction

    • Pulse rate

    • Blood pressure (bilateral for chest pain!)

Focused exam o1
Focused Exam (O) otherwise!

  • Listen to breath sounds

  • Palpate chest

  • Palpate abdomen

  • Check pedal pulses

  • BGL if diabetic with DLOC

  • SpO2 after BP, confirm with pulses, RA & after administration of O2

  • Rhythm strip?

Focused exam o2
Focused Exam (O) otherwise!

  • Based upon your clinical findings

  • Observe the patient while they are talking with you, note any distress/discomfort (Levine sign)

  • Watch for acute clinical signs: jugular vein distension, tracheal deviation, paradoxial chest movement.

Detailed exam o
Detailed Exam (O) otherwise!

  • Complete and thorough neck, head to toe examination with non-critical patients if needed or time permits.

  • Elicit further information and necessary interventions.

  • Key in on critical findings!

Assessment a
Assessment (A) otherwise!

This is your best guess (or rule out) as to what is going on with the patient.

It is based upon YOUR Subjective and Objective findings and should help you develop and implement your Plan for patient care.

Plan p
Plan (P) otherwise!


ABC’s/Monitor vitals

Patient in position of comfort.

Oxygen via ?

Assist with medications.

Maintain body temperature.

Calm and reassure.

Minimize patient movement.

Rapid transport!

Other stuff
Other Stuff otherwise!

  • Coronary artery bypass graft (CABG) and other open heart surgeries

  • Percutaneous transluminal coronary angioplasty (PTCA)

  • Automatic implantable cardiac defibrillators (ACID)

  • Pacemakers